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Epidemiology National Child Abuse and Neglect Data System

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Title: Epidemiology National Child Abuse and Neglect Data System


1
Non-Accidental Trauma (NAT) in Pediatric Patients
  • Joshua Klatt, MD
  • Original Author Michael Wattenbarger, MD March
    2004
  • 1st Revision Steven Frick, MD Revised August
    2006
  • 2nd Revision Joshua Klatt, MD Revised September
    2009

2
Overview
  • Definitions
  • History
  • Epidemiology
  • Evaluation
  • Imaging
  • Differential Diagnosis
  • Clinical Features
  • Nonorthopaedic Features
  • Orthopaedic Features
  • Management
  • Summary

3
Definitions
  • Federal law identifies minimum set of acts that
    characterize maltreatment
  • Defines child abuse and neglect as
  • at a minimum, any act or failure to act
    resulting in imminent risk of serious harm,
    death, serious physical or emotional harm, sexual
    abuse, or exploitation of a child by a parent or
    caretaker who is responsible for the childs
    welfare

4
Definitions
  • 4 Types
  • Physical abuse
  • Infliction of physical injury as a result of
    punching, beating, kicking, biting, burning,
    shaking, throwing, or otherwise harming a child
    with or without intention
  • Neglect
  • Sexual abuse
  • Emotional abuse

5
History
  • Writings from 1st and 2nd century A.D. describe
    afflictions of children who may have been
    stricken intentionally
  • Tardieu, 1860 (Paris)
  • Published 1st article on mal-treatment of
    children
  • Detailed clinical findings, including description
    of fractures
  • Ingraham Matson, 1944
  • Suggested traumatic origin for subdural hematomas
    in infants, rather than infectious etiology

6
History
  • Caffey, 1946 (NY)
  • Radiologist who published 1st systematic review
    of now well-recognized syndrome (AJR)
  • 6 children with chronic subdurals and 23 long
    bone fractures
  • Subsequently more systematic evaluation and study
  • Kempe, 1962
  • Coined term Battered Child Syndrome
  • Described constellation of physical findings of
    children who have been abused with discrepancy in
    reported history
  • Failure to thrive
  • Subdural hematomas
  • Multiple soft-tissue and bony injuries
  • Poor hygiene
  • Greatly increased public awareness, leading to
    improved legislation

7
Epidemiology
  • Inconsistencies in reporting and variation in
    definitions make it difficult to precisely
    determine prevalence and track trends

8
EpidemiologyHow widespread a problem?
  • 1 - 1.5 of children are abused per year
  • In 2005, 3.6 million investigations
  • 899,000 known cases
  • 1460 deaths
  • Estimates suggest that only 50-60 of cases of
    death due to neglect or abuse are actually
    recorded as such

9
EpidemiologyNational Child Abuse and Neglect
Data System (NCANDS) 2007
  • Neglect 59
  • Multiple types 13
  • Physical abuse 11
  • Sexual abuse 8
  • Emotional maltreatment 4
  • Medical neglect lt 1

10
EpidemiologyNational Child Abuse and Neglect
Data System (NCANDS) 2007
  • Perpetrators (non-fatal cases)
  • Parents 80
  • Mother only 39
  • Father only 18
  • Both 17
  • Unknown 10
  • Male relative 3
  • Female relative 2
  • Partner of parent 3

11
EpidemiologyNational Child Abuse and Neglect
Data System (NCANDS) 2007
  • Perpetrators (fatalities)
  • Parents 69
  • Mother only 27
  • Father only 16
  • Both 18
  • Unknown 16
  • Male relative 2
  • Female relative 2
  • Partner of parent 3 (male 2.7, female 0.3)
  • Daycare staff 2

12
EpidemiologyNational Child Abuse and Neglect
Data System (NCANDS) 2007
13
(No Transcript)
14
Epidemiology
  • Unrecognized and returned to home
  • 25 risk of serious injury, 5 risk of death
  • Abuse is second leading cause of mortality in
    infants and children
  • Recognize and get child into safe environment!

Recognition of NAT is important!!
15
EpidemiologyPhysical
  • 80 of deaths from head trauma in children lt 2 yr
    are NAT
  • Fractures are 2nd most common presentation of
    physical abuse (25-50)
  • Estimated 10 of trauma cases seen in ED in
    children under 3 yr are nonaccidental
  • 20 involve burns
  • One third will be seen by an orthopaedist!

16
Risk Factors for NAT
  • Children of all ages, socioeconomic
    backgrounds family types are victims

17
Risk Factors for NAT
  • Young (age lt 3 yr)
  • First born children
  • Unplanned children
  • Premature infants
  • Disabled children
  • Stepchildren
  • Single-parent homes
  • Unemployed parents
  • Substance abuse
  • 50-80 involve some degree of substance abuse
  • Families with low income
  • lt 15k were 25x more likely than gt 30k
  • Children of parents who were abused

High Stress Environments!
18
Evaluation
  • A thorough history and complete general and
    orthopaedic exam are essential
  • Diagnosis of abuse is frequently difficult and
    must include sociobehavioral factors and clinical
    findings

19
Evaluation
  • Team approach helpful - pediatrician, medical
    social worker, subspecialties, law enforcement,
    government child protection agencies
  • Butorthopaedic surgeon may be alone in
    recognition and documentation!

20
Myth
  • Easy to recognize child with NAT

21
Evaluation
  • Age of Patient
  • History
  • Social Situation
  • Other injuries (current and past)
  • Specific injuries/ fractures

22
History
  • Has there been a delay in seeking medical
    treatment?
  • Is the parent reluctant to give an explanation?
  • Is the injury consistent with the explanation
    given?
  • Does the story change between caregivers?
  • Between child and caregiver?

23
History
  • The abused child may be overly compliant and
    passive or extremely aggressive
  • Is the affect inappropriate between the child and
    the parents? (lack of concern, overly concerned)

24
Social Situation
  • Families under stress (loss of job, etc..)
  • Drug or alcohol abuse?
  • Parents in abusive relationships?

25
Social Situation
  • Poor compliance with past medical treatment
  • Children born to adolescent parents
  • Children who suffer from colic
  • Other risk factors?

26
Other Injuries
  • Soft tissue injuries - bruising, burns
  • Intraabdominal injuries
  • Intracranial injuries
  • Multiple fractures in different stages of healing

27
Specific Patterns
  • Most are similar to accidental trauma fracture
    patterns
  • Must rely on other factors, history, physical
    examination, etc. to corroborate
  • Age of child with specific fxs

28
Physical Examination
  • Undress the child!

www.dcmsonline.org
29
Physical Examination
  • Careful search for signs of acute or chronic
    trauma
  • Skin - bruises, abrasions, burns
  • Head - examine for skull trauma, palpate
    fontanelles if open, consider funduscopic exam
    for retinal hemorrhage
  • Trunk - palpate rib cage, abdomen
  • Extremities - careful palpation
  • Genitalia consider exam for sexual abuse

30
Physical Examination
www.boostforkids.org/ images/bodyDiagram500.jpg
31
Radiographic Work-Up
  • Skeletal survey for children with suspicion of
    NAT
  • Babygram not sufficient as does not provide
    necessary detail to identify fractures
  • AAP Section on Radiology recommends mandatory
    survey in all cases of suspected abuse in
    children less than 2
  • Individualized use of survey in children 2-5 yr
  • Not useful in children over 5 yr (exam more
    specific)
  • Yield of surveys in neglect sexual abuse is low

32
Radiographic Work-UpSkeletal Survey
  • AP/LAT skull
  • AP/LAT axial skeleton and trunk
  • AP bilateral arms, forearms, hands, thighs, legs,
    feet
  • Repeat skeletal survey at 1-2 weeks can be
    helpful

33
Bone Scan
  • Usually reserved for highly suspicious cases with
    negative skeletal survey
  • Good at picking up rib and vertebral fxs
  • Repeat bone scan at 2 weeks can identify occult
    injuries

34
Orthopaedic Features
  • 2nd most common presentation (9-55) after
    bruising
  • More common in younger children (demanding,
    nonverbal, defenseless)
  • Children lt 1 yr, 45-55 of fx's associated with
    NAT
  • Children lt 3 yr, 40 associated with NAT

35
Orthopaedic Features
  • Long bone fractures in pre-ambulatory infants in
    absence of metabolic bone disease are more often
    NAT than accidental

36
Orthopaedic Features
  • Fracture pattern not specific (spiral,
    transverse, etc.)
  • Multiple fractures at different stages of healing
    highly specific

37
Kocher Kasser, Orthopaedic Aspects of Child
Abuse, JAAOS 810-20, 2000
38
Fractures in Different Stages of Healing
  • Present in 70 of physically abused children lt 1
    yr
  • Present in 50 of all abused children

39
Fractures Commonly seen in NAT - High Specificity
  • Femur fracture in child lt 1 year old (any
    pattern)
  • Humeral shaft fracture in lt 3 year old
  • Sternal fractures
  • Metaphyseal corner (bucket-handle) fractures
  • Posterior rib fx's
  • Digit fractures in nonambulatory children

40
Myths
  • Myth Spiral Fractures have a high association
    with NAT
  • Actually commonly seen accidental fx pattern
  • Bone is weakest in tension/torsion failure
    mechanism

41
Facts
  • Spiral can occur accidentally
  • Spiral only 8-36 of fxs in NAT series
  • Toddlers fx of tibia common accidental injury

42
Femur Fractures
  • Most femur fx's in children lt 1 yr are from NAT
    (60-70)
  • Most femur fx's in children gt 1 yr accidental
    (60-70)

43
Femur Fractures
  • Recommendations of 2009 AAOS Clinical Practice
    Guidelines for pediatric femur s
  • Children younger than 36 months with diaphyseal
    femur fracture should be evaluated for NAT
  • Level of Evidence II, Grade A recommendation
  • Based on 3 population-based studies
  • 2 reported 14 12 of s were result of abuse
    in children zero to 12 months, and zero to 3
    years, respectively
  • 3rd study reported only 2 of s result of abuse
    among children zero to 15 years
  • Emphasis on history and physical in evaluation
  • Selective use of a skeletal survey when
    considered appropriate by treating physician

44
Metaphyseal Bucket HandleFracture (Corner
Fracture)
45
Corner Fractures
  • Traction/rotation mechanism of injury
  • Planar fracture through primary spongiosa,
    creates disk-like fragment of bone/cartilage,
    thicker at periphery

46
Bucket Handle Fractures
  • Pathognomonic of NAT
  • Less common than diaphyseal fractures, but more
    specific for NAT

47
Humerus Fractures
  • True purely physeal fractures uncommon except at
    distal humerus (traction injury)
  • Transphyseal fxs - high association with NAT
  • Supracondylar fxs common in accidental trauma

48
Transphyseal Distal Humerus Fracture
49
Humerus Fractures
  • Diaphyseal fractures in children lt 3 yr are very
    suggestive of NAT

50
Rib Fractures
  • Secondary to AP or lateral compressive forces
  • Squeezing, direct impact, shaking
  • Present in 5-25 of abused children
  • Posterior posterolateral fractures most common
    and highly specific
  • Although may occur anywhere

51
Rib Fractures
  • Indicator of severe trauma due to relative
    compliance of rib cage
  • Associated with high risk of mortality
  • Even after vigorous CPR, rib fracture is uncommon
    in children
  • Up to 50 of all postmortem fractures are rib
    fractures
  • Only 35 of rib fractures are visible on skeletal
    survey

52
Spine Fractures
  • Only 0-3 of fractures
  • Most asymptomatic compression fractures detected
    on skeletal survey, not often catastrophic
  • Fracture or avulsion of spinous processes if
    fairly specific to abuse
  • Most in lower thoracic and upper lumbar spine
  • May be many levels
  • Secondary to hyperflexion and hyperextension with
    shaking

53
Uncommon in NAT
  • Mid clavicular fractures
  • Simple linear skull fractures
  • Single diaphyseal fractures
  • Especially in children over 18 months

54
Management - NAT Suspected
  • Professional, tactful, nonjudgmental approach in
    initial encounter and workup
  • Explain workup to parents as standard approach to
    specific ages/injury patterns
  • Early involvement of child protection team if
    available
  • Early contact/involvement of childs primary care
    physician

55
Management - Documentation
  • Many cases result in medical records becoming
    part of legal record
  • Carefully document history, physical exam and
    radiographic findings
  • Document evidence supporting physical abuse
  • Document statement regarding level of certainty
    of abuse

56
Legal Aspects of NAT
  • All states require reporting of suspected cases
    of abuse by medical professionals
  • Need only reasonable suspicion to report
    suspected maltreatment
  • Law affords immunity from civil or criminal
    liability for reporting in good faith

57
Differential Diagnosis - NAT Fractures
  • Accidental trauma
  • Osteogenesis Imperfecta
  • Metabolic Bone Disease (rickets, etc.)
  • Birth trauma
  • Physiologic periostitis

58
Osteogenesis Imperfecta
  • Type II and III obvious bony disease
  • Type I family history and blue sclera
  • Frequent dental involvement
  • Osteopenia
  • Wormian bones in skull
  • Remember blue sclera may be normal until 4 yrs of
    age

http//xakimich.hp.infoseek.co.jp/Image/blue-scler
a-1.jpeg
http//www.mypacs.net/repos/mpv3_repo/viz/full/170
63/853184.jpg
59
Osteogenesis Imperfecta
  • Type IV heterogeneous with mild to moderate
    disease, normal sclera, no dental involvement
    minimal osteopenia
  • With no family hx, blue sclera, or wormian bones
    the chance of a new mutation is 1 in 3 million

60
Summary
  • Child abuse is pervasive
  • Major cause of disability and death among
    children
  • Diagnosis involves careful consideration of
  • Sociobehavorial factors
  • Clinical findings

61
Summary
  • Fractures are second most common presentation of
    physical abuse, after skin lesions
  • No pathognomonic fracture pattern of abuse
  • Suggestive findings include
  • Certain metaphyseal lesions
  • Multiple fractures in various stages of healing
  • Posterior rib fractures
  • Long-bone fractures in children less than 3 years
    old

62
References
  • Akbarnia BA, Akbarnia NO. The role of the
    orthopedist in child abuse and neglect. Orthop
    Clin North Am 1976 7 733-42.
  • Kocher MS, Kasser JR. Orthopaedic aspects of
    child abuse. Journal of the American Academy of
    Orthopaedic Surgeons 2000 8( 1) 10-20.
  • http//www.childwelfare.gov/pubs/factsheets/fatali
    ty.cfm
  • http//www.acf.hhs.gov/programs/cb/pubs/cm07/index
    .htm
  • http//www.aaos.org/research/guidelines/PDFFguidel
    ine.asp

63
Summary
  • Management should be multidisciplinary
  • Risk of repeated abuse and death are substantial

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